Spontaneous intracranial hypotension with magnetic resonance localisation of spinal cerebrospinal fluid leak

Treatment strategy for cerebral hypotension caused by spontaneous cerebrospinal fluid leaks

OBJECTIVE

Spontaneous spinal cerebrospinal fluid (CSF) leaks are rare (5 per 100,000 per year). Treatment generally consists of conservative therapy or interventional therapy with epidural blood patching. Surgical treatment is conducted rarely, usually in cases when conservative or interventional treatment has failed. The aim of our case series was to assess the clinical outcome after surgery.

METHODS

Our clinical database was reviewed for patients with spontaneous spinal CSF leaks who underwent surgical exploration between 2010 and 2013. Etiology, symptoms, preoperative imaging, type of required surgical method, intraoperative findings, and clinical outcome were reported.

RESULTS

We identified five patients with a mean age of 62 years with spontaneous spinal CSF leaks who were treated surgically. Two patients received surgery after failure of interventional treatment. The origin of the CSF leak could be identified intraoperatively in three cases. Surgical technique in all cases consisted of an interlaminar fenestration or hemilaminectomy and a complete foraminotomy to explore the thecal sack and the exiting nerve roots and identify the CSF leak. After surgery, the preoperative symptoms improved in all patients. In one case, there was a relapse after 4 weeks.

CONCLUSIONS

Preoperative identification of a CSF leak with MRI was positive in only one case. In all other cases, a post-myelography CT had to be performed. In all cases, the preoperative symptoms improved after surgery. Surgical treatment is an effective treatment of spontaneous cerebrospinal fluid leaks in cases of refractory symptoms after failed conservative or interventional treatment.

A quantitative study of intracranial hypotensive syndrome by magnetic resonance

OBJECTIVES

The study aims to investigate the magnetic resonance imaging (MRI) findings of intracranial hypotension syndrome (IHS) and the change of quantitative indicators, so as to yield a deeper understanding of the disease.

PATIENTS AND METHODS

The clinical data and MRI findings of 26 cases of IHS which were confirmed by lumbar puncture were retrospectively analyzed. Two physicians evaluated the MRI findings including thickening and enhancement of dural, pituitary enlargement, subdural effusion (hematocele), venous engorgement and brain sagging, and measured the quantitative indicators including mamillopontine distance and pontomesencephalic angle. The consistency between the two results of the physicians was assessed by Kappa consistency test. The differences of mamillopontine distance and pontomesencephalic angle between the patient group and the control group were determined by paired t-test. The diagnostic efficiency of mamillopontine distance and pontomesencephalic angle was assessed by area under the ROC curve, and their best diagnostic thresholds were also determined, respectively. Age- and sex-matched healthy volunteers controls (n=26) were recruited and served as the control group.

RESULTS

All of the 26 patients suffered from the characterized by orthostatic headache of IHS. The clinical evaluations of dural thickening and enhancement, pituitary enlargement, subdural effusion (hematocele), venous engorgement by the two physicians showed excellent agreements (κ=0.808, 1 and 0.906, P<0.01), and the clinical evaluations of brain sagging showed medium agreements (κ=0.606, P<0.01). The mamillopontine distance and pontomesencephalic angle of the patient group were 5.4 ± 1.6mm and 47.8 ± 8.7°, respectively, which were obviously less than those of the control group (6.9 ± 1.1mm and 61.0 ± 6.1°, respectively), and the differences were statistically significant (t=-4.563, P<0.01; t=-.329, P<0.01). The area under ROC curve of mamillopontine distance and pontomesencephalic angle were 0.774 and 0.908, respectively, and the diagnostic value of pontomesencephalic angle was higher than that of the mamillopontine distance. The sensitivity and specificity were 73.1% and 73.1%, respectively, when diagnostic threshold of mamillopontine distance was 6.4mm. The sensitivity and specificity were 76.9% and 96.2%, when diagnostic threshold of pontomesencephalic angle was 51.7°.

CONCLUSION

The MRI findings presented characteristic features of IHS. The quantitative indicators including mamillopontine distance and pontomesencephalic angle were helpful for clinical diagnosis of subjective findings of IHS.